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When you have a hope

Feature story

December 2013 - During the XVII International Conference on AIDS and STIs in Africa (ICASA), I drove to the Ubuntu HIV clinic located in Khayelitsha, an ever-expanding informal township just outside Cape Town. Home to up to a million people, the informal township was the first place in the country where HIV treatment was delivered and provides a sound reality check on the messages echoing in the ICASA halls. The Ubuntu clinic was set up amidst the early days of HIV treatment crisis in South Africa and now has the largest number of patients enrolled on antiretrovirals (ARVs) in the country. Spread through a set of simple, single-storey buildings, the clinic was first started by Médecins Sans Frontières (MSF) in 2001 then transferred to the Government in 2005. The clinic now serves over 8000 people living with HIV from the surrounding districts in Khayelitsha.

Success of task-shifting

On this sunny day in Cape Town, the clinic is half full of patients: men, women and fewer children waiting and meeting with nurses and counselors, leaving the clinic with plastic bags full of medications. I was met by a much energetic nurse Nompumebelo Mantangana or Sis Mpumie as she is widely known among patients at the clinic and treatment activists in the country.

Sis Mpumie has worked as a nurse for over three decades and has been working at Ubuntu clinic since 2000. Today, nurses and counselors provide a large portion of the patient care through “task-shifting” so that doctors focus on complex cases, and they look after the majority of patients on ART. “The reason you don’t see many sick people in our clinic today is because most of them are HIV positive people in stable health, taking their ARVs for years,” explains Sis Mpumie. “They come once in two months or so to get their ARVs”.

Adherence clubs

Over the years, the clinic staff had to stay ahead of the curve and invent new methods to deal with an ever increasing number of patients. One of the more recent innovations highlighted by Sis Mpumie was the establishment of adherence clubs. “Today, many of our patients attend the adherence clubs, which are counselling sessions and treatment literacy trainings facilitated by our nurses, counselors, peer educators, in libraries, schools, community halls and churches,” she said. “These clubs take a lot of workload off the clinical staff, so that they can focus on more complicated cases and new patients, while stable patients get more support and advice from community workers and from each other.”

Daily, single HIV medicine reaching new patients

In June 2013, WHO released the consolidated ARV guidelines which recommended the use of a single ARV regimen, preferably to be used as a fixed-dose combination. This means doctors are advised to put patients on a single ARV combination therapy - TDF,3TC (or FTC) +EFV - to be taken only once a day.

Here in Ubuntu, the Government started the supply of daily HIV pill manufactured in South Africa in April, even before the WHO’s global guidelines’ launch. Sis Mpumie and colleagues were overjoyed to be able to start new patients on this drug. “This was like a dream coming true for us,” Sis Mpumie said. “This is so much better than patients having to take various drugs at different times of the day. So far, only a portion of patients are on this efficient regimen, as others have to wait until they are transitioned.”

There is a sad reality that sets in when we talk about paediatric ARV treatment. At Ubuntu clinic, some 400 children are enrolled on ARVs. But the drugs are many, some of them are chunky-sized. “Look at these drugs that these little children have to take,” Sis Mpumie showed. “Some of these medications are syrups, which use complicated measuring tools and some of them need to be taken in combination with other drugs, that can be big pills. Many of the kids are looked after by their grannies, and we need to teach them how to follow these treatments, which can be complicated. We urgently need children-friendly HIV medications, and it’s a shame that we have neglected the plight of our HIV-positive children, till this late.”

Here in Ubuntu clinic, we are reminded why we cannot slow down our work tackling HIV and TB jointly. In this community, 70% of the patients are co-infected with HIV/TB. In response to this high rate of co-infection Ubuntu clinic has pioneered much needed integrated care: patients who test for HIV also test for TB and receive necessary treatments for both diseases. Beyond TB, the clinic also aims to further integrate care by supporting referrals for maternal, child care and non-communicable diseases.

Most of the 8 000 people living with HIV accessing ART at Ubuntu clinic are on first- and second-line HIV treatments, which are funded by the Government of South Africa. However, a select few are on third-line regimen which are extremely expensive and currently provided by MSF.

When you have clinics like Ubuntu, you are giving hope to thousands of people living in townships like Khayelitsha. Majority of these people are enjoying stable health and go on with their lives, even if they encountered formidable health problems like HIV and TB. But the hope needs to be equally spread for all people, no matter what line of ARV treatment they require, or what type of TB they got, and above all, for the children who shouldn’t struggle with more difficult treatment than the ones even adults could struggle with.

These were some of the key messages coming out of the XVII ICASA conference that gathered over 7 000 policy and programme planners on HIV in Africa in downtown Cape Town. Much success gained in Africa’s HIV response is visible both there and here in Khayelitsha, but without equal hope provided to all, those most vulnerable will continue be turned away from HIV services.